Basic Information
| Provider Information | |||||||||
| NPI: | 1962455881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF SOUTH ALABAMA HEALTH SERVICES FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 FILLINGIM ST | ||||||||
| Address2: | MASTIN BLDG. 617 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | TATE | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2514705842 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | AL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GSD600 | 05 | AL | MEDICAID | 1445061 | 05 | LA | MEDICAID | F882 | 01 | AL | BCBS COMMON PAY # | OTHER |